C O R P O R AT I O N
Flattening the Trajectory of Health Care Spending
Promote Population Health
Key Findings
■Although
a majority of the premature deaths in the United States are due to
behavioral and environmental factors, our country allocates only 5 cents of
every health care dollar to prevention.
■Reversing
the rising tide of obesity and further reducing rates of tobacco use
could produce substantial long-term dividends in terms of lives saved and
disabling illnesses prevented.
■Local
communities and employers have an important role to play in promoting
population health. At present, the tools available to help communities are
better developed than those of employers.
■Health
promotion begins in the family. Parents and peers are powerful
influences on the health-related choices of children and youth.
The Policy Challenge
Social and behavioral factors influence the health of Americans as surely as do the efforts of
physicians, nurses, and hospitals. To slow health care spending growth, we need to do a better job
of addressing the determinants of disease, rather than waiting to treat its consequences. It is estimated that 70 percent of deaths in the United States and a comparable share of health care spending
are due to behavioral or environmental causes,1, 2 but only 5 percent of our nation’s annual spending
on health is directed toward reducing key health risks.
The nation pays a high price for neglecting the possibilities of prevention. For example,
high blood pressure dramatically increases the risks of heart disease, stroke, and kidney failure—
all of which are major causes of death, disability, and spending through Medicare. Yet, according to
This series of research briefs presents insights from RAND Health research about the effectiveness of strategies to constrain growth in health care spending.
A summary brief synthesizes findings from more-detailed discussions focusing on four broad categories of policy options: (1) foster efficient and accountable
providers, (2) engage and empower consumers, (3) promote population health, and (4) facilitate high-value innovation.
Insights for the Second Obama Administration and 113th Congress
Figure 1. Projected Lifetime Costs of Obesity to Medicare
(2012 dollars)
Overall
Obese
Overweight
Normal weight
Underweight
0
50,000
100,000
150,000
200,000
Lifetime costs to Medicare
SOURCE: Data are drawn from Exhibit 3 in Lakdawalla DN, Goldman DP,
and Shang B, 2005.9
NOTE: Dollar figures are inflated from 2005 to 2012 using the medical
Consumer Price Index.
2
the Centers for Disease Control and Prevention (CDC), fewer
than half of the 68 million Americans with hypertension are
currently on an adequate regimen of treatment.3 Analyses using
RAND’s Future Elderly Model projected that Medicare could
save up to $890 billion between 2005 and 2030 if high blood
pressure were effectively controlled.4
This brief presents insights from RAND research about the
potential value of focusing on population health, particularly
the risks of obesity and smoking. It also examines opportunities
to promote health at the local level and within families.
Obesity
Obesity dramatically increases an individual’s risk of developing a wide variety of costly and debilitating diseases, including
diabetes, heart disease, cancer, and arthritis. Obese individuals
with these problems also tend to have a poorer disease prognosis than non-obese individuals. Indeed, the health consequences
of obesity are even worse than those associated with smoking
and problem drinking.5
A Growing Epidemic. Over the last decade, the rate of
clinically severe obesity—a body mass index (BMI) of 40 kg/m2
or greater—increased by 70 percent; today, more than 15 million
Americans are clinically obese. But the prevalence of morbid obesity (BMI greater than 50 kg/m2) increased even more rapidly.6
Obese individuals, on average, incur health care costs
one-third higher than persons of normal weight, but severely
obese individuals incur health care costs that are twice as high
(Figure 1).7, 8
A recent RAND study showed if we were able to cut the
current rate of obesity in the United States in half—basically,
the level we were at in 1978—it would reduce the burden of
such costly health problems as diabetes, hypertension, and heart
disease; increase longevity and years of disability-free life; and
significantly decrease Medicare and Medicaid costs.10 Savings to
the Medicare program alone were projected to reach $1.2 trillion
by 2030.11
Responding to the Epidemic. The basic issue is straightforward:
People gain weight when they consume more calories than they burn.
Because social, structural, and environmental cues play a substantial
role in what—and how much—we choose to eat, these cues can
be used to gently “nudge” people to develop more- or less-healthful
eating habits. For example, research indicates that the amount most
people eat in a given day is significantly influenced by portion size
and the ubiquitous accessibility of high-calorie foods.12, 13, 14
Insights for the Second Obama Administration and 113th Congress
RAND has examined a number of promising policy
options for reducing rates of obesity.15 Studies show that parks
promote exercise,16, 17 while school playgrounds offer an underused resource for weekend exercise. Consumption of fruits and
vegetables is lower in disadvantaged neighborhoods,18 suggesting that efforts by community groups, businesses, or government to increase the availability of fresh produce and other
healthy foods in disadvantaged neighborhoods may be worth
pursuing. More intrusive public policies that could make a difference include imposing higher taxes on sugary soft drinks and
junk food, as well as standardizing portion sizes. More extreme
measures, such as neighborhood moratoriums on opening or
expanding fast food restaurants, are unlikely to be effective.19, 20, 21
As for conventional medical options, bariatric surgery
remains the only effective approach to manage severe obesity.22
Compared with many other procedures, it is relatively costeffective. But is it the best approach for society? In the United
States, the number of bariatric surgical procedures for weight
loss increased from 13,000 in 1998 to about 220,000 in 2009,
according to the American Society for Bariatric Surgery.23 But
the explosive increase in the use of this procedure failed to make
a dent in rates of morbid obesity, which grew at twice the rate of
moderate obesity.24 So surgery does not appear to be the answer.25
Considered as a whole, RAND’s findings suggest that our
nation’s approach to controlling obesity should be rethought.
Public campaigns to prevent obesity have focused on nutritional
guidelines, diets, and food labels with nutritional information.
These efforts assume that, armed with proper information,
people will consume fewer calories. But this presumes that eating is a conscious act.
RAND’s research, and the work of others, suggests that
eating is influenced more by environmental factors than conscious choice.26 If this assumption is confirmed by future studies,
then instead of relying on public educational or motivational
approaches to reduce food consumption, efforts should focus on
altering the environmental cues that encourage overeating.
Smoking
Rates of smoking have declined dramatically since release of the
Surgeon General’s 1964 report, Smoking and Health.27 Nevertheless, smoking remains the leading preventable cause of death in
the United States.28 Today, 22 percent of U.S. adults—roughly
66 million people—use tobacco products.29, 30 Cigarette smoking, reported by nearly 20 percent of the adult population,31, 32
is a leading cause of coronary heart disease, stroke, and chronic
obstructive lung disease,33 and it is responsible for nearly
one-third of all cancer deaths.34 It also costs public and private health plans roughly $96 billion per year, excluding costs
from secondhand smoke and productivity losses.35 Smokeless
tobacco, currently used by about 4 percent of U.S. adults,36 produces many of the same health harms as smoking. Youth who
use smokeless tobacco are more likely to become smokers.37
The fastest way to reduce current population-based smoking rates is to help smokers quit. However, the best way to lower
rates over the long term is to discourage children and youth from
starting to smoke.38 RAND researchers have studied a number of
promising strategies for achieving both goals, including examining the influence of peers and coworkers on uptake of smoking39, 40
and changing how smoking is portrayed in the media.41
In 2001, the states played a historic role in tobacco control
by banding together to successfully sue tobacco manufacturers
for the harms caused by their products. The massive settlement
that ended the lawsuit not only generated substantial funding
for tobacco control—it also indirectly boosted the prices of
tobacco products, which discouraged sales.42 The states can
continue to play a constructive role in tobacco control in three
important ways: tax policy, smoke-free air laws, and ongoing
support of tobacco prevention and cessation programs.43 The tobacco control program in Arkansas is a noteworthy
example.44 After the program was put into effect in 2001, the
state’s smoking rate fell more quickly than the rate in six neighboring states. Today, half as many young people in Arkansas smoke
as did a decade ago. The state’s declining rate of smoking appears
to have produced dividends for its population. By 2008, far fewer
young people in Arkansas smoked than when the program began
(Figure 2).45 A year later, in 2009, the rate of youth smoking in
Arkansas was half that of a decade earlier. In 2010, statewide rates
of hospitalization for heart attacks and strokes—both smokingrelated conditions—were one-third lower than in 2000.46
Promoting Health at the Local Level
Substance use prevention programs can improve the behavioral
health of communities, as well as saving four to five dollars for
every dollar invested in drug abuse treatment and counseling.48
However, local health departments and prevention practitioners
face several challenges in implementing high-quality prevention
programs, including the significant amount of knowledge and
skills required to create effective programs, the multiple steps
3
Insights for the Second Obama Administration and 113th Congress
Figure 2. Decreases in Smoking Prevalence Among Young
People in Arkansas, 2000–2008
40
35
High school students
Pregnant teenagers
30
25
20
15
10
5
0
2000 rate
2005 rate
SOURCE: Schultz D et al., 2010.47
4
2007 rate
2008 rate
involved, and the wide variety of contexts in which prevention programs need to be implemented. These challenges have
resulted in a large gap between the positive impact achieved
by prevention science and the lack of comparable outcomes by
public health practitioners at the local level.
Support for Community Substance Prevention Programs.
To bridge this gap, a team of researchers at RAND and the University of South Carolina developed Getting To OutcomesTM
(GTO), a science-based model and associated support tools
designed to help communities plan, implement, and evaluate
programs aimed at preventing or reducing a range of negative
activities among youth.49 The GTO model has successfully
translated research into practice—it is prescriptive, yet flexible enough to strengthen any prevention program. Although
the model was originally aimed at preventing youth drug and
tobacco use, it has also been used to support community programs targeting crime, teen pregnancy, delinquency, underage
drinking, intimate partner violence, and sexual violence.50, 51
Workplace Wellness. The public sector is not the only
avenue for strengthening population health: Employers can
play a role as well. A growing number of employers are implementing workplace wellness programs in an attempt to promote
healthy lifestyles, prevent disease, reduce absenteeism, enhance
employee productivity, and lower health care costs. Most programs combine a mix of educational (e.g., diet counseling)
and motivational incentives (e.g., providing financial and nonfinancial incentives to encourage lifestyle changes).52 In 2009,
58 percent of U.S. employers offered at least one type of wellness program.53 Consumer participation, currently averaging a
little more than 20 percent, is gradually rising.54 These trends
are likely to accelerate as employers take more-aggressive action
to limit rising health care costs.55
However, the growth of workplace wellness programs is outpacing the underlying evidence. Research compiled since 2000
provides mixed evidence of program effects.56 Given employers’
strong interest in wellness, and the emphasis placed on worksite
health promotion in the Affordable Care Act, rigorous evaluations are needed to identify, assess, and refine effective programs.
Worksite wellness efforts may increase costs in the short term
before reducing them in the longer term. A RAND-led evaluation
of PepsiCo’s health and wellness program examined the program’s
return on investment for the company.57 In its first year of operation, the program increased per member per month (PMPM) costs
by $66, but in the second and third years of the program, PMPM
Insights for the Second Obama Administration and 113th Congress
costs declined by $76 and $61, respectively. Over all three years,
the program was associated with reduced PMPM costs of $38, a
decrease of 50 emergency room visits per 1,000 member-years, and
a decrease of 16 hospital admissions per 1,000 member-years.
RAND’s evaluation examined a single program, so it may
not generalize to other workplace settings. However, these findings suggest that companies should adopt a longer-term view
when implementing a new program. RAND is currently conducting additional evaluations of workplace wellness programs
and will release more findings in the months to come.
The Family’s Role in Promoting Health
The goal of health promotion is to make the “healthy choice
the easy choice.”58 RAND researchers have identified numerous
factors that are associated with healthy decisions in childhood,
adolescence, and adulthood. Two of the most important forces
that parents should monitor are media influences and the
reinforcement of peers.
Media Influences. The media plays a very important role in
defining social norms and signaling to children and adolescents
what behaviors are acceptable, or even admirable. These effects
are a particular concern for children and adolescents, who
may be more susceptible to harmful messages because of their
youth. In addition, individuals who adopt unhealthy behaviors
in their youth, such as smoking, tend to continue those behaviors throughout their lives.
Over the past decade, RAND researchers have found
links between media exposure and the initiation of smoking,
alcohol use, and sexual activity. Youth exposed to ads or movies featuring cigarette or alcohol use are more likely to initiate
smoking59, 60, 61 and drinking behaviors.62, 63 The RAND Television and Adolescent Sexuality Study demonstrated a relationship between viewing sexual content on TV and the subsequent
initiation of intercourse, as well as teenage pregnancy.64, 65, 66
Obviously, media content is not readily amenable to public
policy action, due to First Amendment concerns. However, parents can shield young children from unhealthy media messages
and counter messages aimed at older children through regular
communication and by serving as a good role model.67
Peer Influences. RAND research has also shed light on
the powerful role that family and peer social networks play in
influencing risky behaviors, such as substance and alcohol use,
smoking, overeating, and physical inactivity. Although peer
networks are frequently implicated in the initiation of risky
behavior, positive peer relationships can also be leveraged to
exert protective effects.
The positive and negative effects of peer relationships
informed the development of one of RAND’s most successful programs: Project ALERT, a school-based drug and alcohol
prevention program.68 In contrast with other programs that have
produced disappointing results, Project ALERT has been shown
to be highly effective at reducing rates of student substance use.69
When first created in the 1980s, Project ALERT represented a departure from typical, education-focused prevention
activities. It recognized that a key dimension of adolescent substance use is the social environment in which children are pressured to engage in risky activities. Project ALERT targets these
social norms while giving students tools to recognize and resist
social and media pressure to drink and do drugs. Initially tested
among middle school students, the program was subsequently
extended to the 9th grade, where it curbed weekly alcohol and
marijuana use, at-risk drinking, and attitudes conducive to
drug use among at-risk girls.70
Project ALERT is now the most widely used research-based
drug prevention program in the United States. It is distributed
by the BEST Foundation, which periodically updates program
materials and offers training and technical assistance to encourage school-wide or district-level adoption of the program.71
The resistance skills that Project ALERT teaches remain
long after the formal program is completed. Compared with
peers who had not received the program, youth exposed to
Project ALERT as adolescents were significantly less likely as
young adults to either engage in sex with multiple partners or
have unprotected sex because of drug and alcohol use.72
Conclusion
A broad range of social, behavioral, and environmental factors
influence Americans’ health as surely as does the treatment
provided by doctors, clinics, and hospitals. But because population health measures typically have long lead times to produce
results, they are rarely considered in discussions of policy
options to limit growth of health care spending. If spending on
health care crowds out national and state-level investments in
public education, environmental protection, and other important contributors to population health, our nation’s downstream health care costs may be greater still.
5
Insights for the Second Obama Administration and 113th Congress
Notes
1
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RB-9508, 2011. http://www.rand.org/pubs/research_briefs/RB9508/
index1.html
2
Institute of Medicine, Promoting Health: Intervention Strategies from
Social and Behavioral Research, June 25, 2000. http://iom.edu/Reports/
2000/Promoting-Health-Intervention-Strategies-from-Social-andBehavioral-Research.aspx
16
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Treatment, and Control of Hypertension—United States, 1999–2002
and 2005–2008,” Morbidity and Mortality Weekly Report, Vol. 60, No. 4,
February 4, 2011, pp. 103–108. http://www.cdc.gov/mmwr/preview/
mmwrhtml/mm6004a4.htm?s_cid=mm6004a4_w
17
Cohen D et al., “How Neighborhoods Can Reduce the Risk of
Obesity,” Santa Monica, Calif.: RAND Corporation, RB-9267-HLTH,
2007. http://www.rand.org/pubs/research_briefs/RB9267/index1.html
3
Goldman DP et al., “Modeling the Health and Medical Care Spending
of the Future Elderly,” Santa Monica, Calif.: RAND Corporation,
RB-9324, 2008. http://www.rand.org/pubs/research_briefs/RB9324/
index1.html
4
Sturm R, “The Effects of Obesity, Smoking, and Drinking on Medical
Problems and Costs,” Health Affairs, Vol. 21, No. 2, March/April 2002,
pp. 245–253. http://www.rand.org/pubs/reprints/RP1003.html
5
Sturm R and Hattori A, “Morbid Obesity Rates Continue to Rise
Rapidly in the United States,” International Journal of Obesity (London),
September 18, 2012. http://www.rand.org/pubs/external_publications/
EP51074.html
6
Sturm R, “The Effects of Obesity, Smoking, and Drinking on Medical
Problems and Costs,” Health Affairs, Vol. 21, No. 2, March/April 2002,
pp. 245–253. http://www.rand.org/pubs/reprints/RP1003.html
7
Andreyeva T, Sturm R, and Ringel JS, “Moderate and Severe Obesity
Have Large Differences in Health Care Costs,” Obesity Research, Vol. 12,
No. 12, December 2004, pp. 1936–1943. http://www.rand.org/pubs/
external_publications/EP20041222.html
8
Lakdawalla DN, Goldman DP, and Shang B, “The Health and Cost
Consequences of Obesity Among the Future Elderly,” Health Affairs—
Web Exclusive, September 26, 2005, pp. W5-R30–W5-R41. http://www.
rand.org/pubs/external_publications/EP20050913.html
9
Sturm R et al., “Preventing Obesity and Its Consequences: Highlights
of RAND Health Research,” Santa Monica, Calif.: RAND Corporation,
RB-9508, 2011. http://www.rand.org/pubs/research_briefs/RB9508/
index1.html
10
Goldman DP et al., “Modeling the Health and Medical Care Spending
of the Future Elderly,” Santa Monica, Calif.: RAND Corporation,
RB-9324, 2008. http://www.rand.org/pubs/research_briefs/RB9324/
index1.html
11
Cohen DA and Farley TA, “Eating as an Automatic Behavior,”
Preventing Chronic Disease, Vol. 5, No. 1, January 2008, p. A23. http://
www.rand.org/pubs/reprints/RP1326.html
12
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external_publications/EP51111.html
13
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Santa Monica, Calif.: RAND Corporation, RB-9361, 2008. http://www.
rand.org/pubs/research_briefs/RB9361/index1.html
14
6
15
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18
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Misses the Mark,” Santa Monica, Calif.: RAND Corporation, RB-9489,
2009. http://www.rand.org/pubs/research_briefs/RB9489/index1.html
19
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20
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21
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22
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23
24
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25
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26
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27
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29
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Insights for the Second Obama Administration and 113th Congress
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36
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This research brief was written by Ramya Chari, Peter S. Hussey, Andrew Mulcahy, David Lowsky, Mary E. Vaiana, and Arthur L. Kellermann.
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